Wrong Site Surgery Persists Despite Preventive Measures

It’s hard to believe that operations on the wrong body part or on the wrong patient still happen.  Yet, according to the Joint Commission on Accreditation of Health Care Organizations (“JCAHO”), surgeons have operated on the wrong leg, eye, kidney or other body part 150 times since 1996.  Most of the time these cases are quietly settled, but sometimes they become headline news. 

A few notorious examples are illustrative of this point.  A patient admitted to a Tampa, Florida, hospital in 1995 for an amputation of a gangrenous foot had the wrong foot removed.  In New York, a patient had surgery on the wrong side of his brain at Sloan-Kettering Cancer Center. A surgeon, nationally recognized for his work with breast cancer patients, confused two patients and performed a mastectomy on the wrong patient in November 1998.

JCAHO, alarmed at the continued high incidence of surgical mistakes, issued a sentinel alert advising patients to become involved in ensuring that the surgical site is well marked before undergoing surgery.  This alert, issued in December 2001, is the second sentinel alert on the same type of medical error.  The first alert focused on wrong site surgery was issued in 1998, and included a review of 15 cases that had been reported to JCAHO.  Of the150 reported cases in the current database, operations on the wrong body part accounted for 76% of the cases, while operations on the wrong patient accounted for 13% of the cases.  The wrong surgical procedure was involved in 11% of the cases.

What is even more alarming is that JCAHO’s figure may actually understate the true incidence of wrong site surgery.   Health care providers are not required to report sentinel events to JCAHO.  They report these events voluntarily. In fact, of the 150 cases, only 81% were self-reported by providers.  The Physician’s Insurance Association of America discovered 331 claims for wrong site surgery in the ten year period from 1985 to 1995 when it reviewed claims from 22 malpractice carriers representing 110,000 physicians. And, even this number could be too low because not every case results in a claim.

Wrong site surgery can have serious consequences for both patients and health care providers.  In response to the first alert in 1998, the American Academy of Orthopedic Surgeons adopted the “Sign your Site” program of preoperative surgical site identification.  Surgeons were encouraged to initial the intended operative site using a permanent marker.  According to Dr. Terry Canale, past President of the American Academy of Orthopedic Surgeons, the Academy discovered that after a two year period of this campaign only 60% of surgeons were marking their operative sites. 
 

JCAHO is now encouraging patients to take an active role in assuring that surgeons operate on the correct site.  According to JCAHO, patients should do two things: (1)discuss specifically what will be done during the surgery with both the surgeon and anesthesiologist, and (2) have the surgical site marked with a permanent marker in the presence of their surgeon, then have the surgeon initial the site.

The alert also offers concrete steps for providers to reduce the risk of wrong site surgery. The JCAHO recommends providers:

* require that the surgical site be marked.
* develop verification checklists.
* require each member of the surgical team to orally verify the identity of the patient, the planned surgical procedure and the site, with the patient, after the patient arrives in the operating room.
* call a “time out” for the surgical team before the actual surgery begins to verify the patient, procedure and site.
         
In 1975, the Louisiana legislature limited damage awards in medical malpractice actions to $500,000, exclusive of future medical expenses and legal interest.  Despite multiple challenges to this limit on constitutional grounds, the medical malpractice cap remains in effect.   But providers should beware.  Wrong site surgery is clearly avoidable and can result in devastating consequences for patients.  Thus, it is imperative that health care providers quickly adopt effective preventive measures designed to eradicate wrong site surgery, or face the real possibility of losing the medical malpractice cap.  Continued wrong site surgery errors may provide opponents of the cap with enough ammunition to finally eliminate it, leaving providers vulnerable to unlimited damage awards.  What the legislature giveth, the legislature can taketh away.

By focusing national attention on this issue, JCAHO hopes to eliminate these avoidable mistakes.   Lets hope that a third sentinel alert on this subject will not be necessary.